Cultural Competence in Caring for African Americans with HIV June 10, 2016 Alexis Powell, MD Associate Professor, UM Dept. of General Medicine Division of Infectious Diseases
Objectives 1. Review the contribution of bias to health disparities. 2. Define cultural competence. 3. Review the HIV burden in African Americans. 4. Look at aspects of health care where cultural competence may be usefully applied.
Seminal Health Disparities Inquiry In 1999, Congress charged the Institute of Medicine (IOM)with evaluating racial/ethnic disparities in health. - More than 100 studies were reviewed - Variables controlled: access, race vs. severity/progression, place of care etc.
IOM Findings: Disparities exist in a number of disease areas and are found across a range of procedures The majority of studies find disparities in clinical services that are equally effective for all racial and ethnic groups. http://www.nationalacademies.org/hmd/~/media/files/report%20files/2003/unequa l-treatment-confronting-racial-and-ethnic-disparities-in-health- Care/Disparitieshcproviders8pgFINAL.pdf
bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care. http://www.nationalacademies.org/hmd/~/media/files/report%20files/2003/unequa l-treatment-confronting-racial-and-ethnic-disparities-in-health- Care/Disparitieshcproviders8pgFINAL.pdf
Bias: a particular tendency, trend or inclination, feeling or opinion especially one that is preconceived or unreasoned Credit: NASA, ESA, and A. Feild (STScI) http://www.nasa.gov/mission_pages/hubble/science/outofwack.html
Qualities of a Good Physician via Google i-studentglobal AUA WebMD Soliant Health Professionalism Compassion Confident Confident Empathy Strong Work Ethic Empathetic Empathetic Attentiveness Professionalism Humane Skilled Forward Thinking Knowledge Personal Focused Composure Confidence Forthright Knowledgeable Industrious Humility Respectful Passion Thorough Lives and Promotes a Healthy lifestyle Respectful Honest and Forthright Humane
Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities Elizabeth N. Chapman, 2013 Physicians demonstrate implicit bias favoring whites and view black patients as uncooperative http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3797360/
Provider Contribution to Health Disparities VanRyn, et al, AJPH 2003 * Lower expectations for minority patients (e.g. tight control of diabetes) * Less effort spent communicating with minority patients (e.g. influenza vaccine) * Gatekeeper bias- (e.g. African-Americans with renal failure less likely to be placed on renal transplant list - not related to patient preference)
Everyone has bias: Recognizing and managing personal bias is essential to developing cultural competence. https://managingbias.fb.com https://implicit.harvard.edu
Why Focus on Bias? Because Every Encounter is a Cross-Cultural One. Hippocratic Oath is inadequate Joint Commission mandates it Federal Laws State Laws Good Practice!
Cultural Competence Administration on Developmental Disabilities, 2000 services, supports or other assistance that are conducted or provided in a manner that is responsive to the beliefs, interpersonal styles, attitudes, language and behaviors of individuals who are receiving services, and in a manner that has the greatest likelihood of ensuring their maximum participation in the program. DHHS, Administration on Developmental Disabilities, 2000, retrieved from Curricula Enhancement Module Series, A Project of the National center for Cultural Competence, Georgetown University Center for Child and Human Development, http://www.nccccurricula.info/culturalcompetence.html, May 6, 2016.
Cultural Competence Continuum Adapted from Cross, et al, 1988,1989 and Ponterotto,1988, retrieved from https://www.pakeys.org/uploadedcontent/docs/elinpa/ell%20toolkit/cross%20cultural%20competence.pdf May 7 2016. Destructiveness Advanced Cultural Competence Incapacity Blindness Pre-competence
Variables of Systemic Vulnerability Discrimination and Segregation Healthcare access/outcomes gap Poverty and Incarceration Stigma
HIV Burden in African Americans, 2014 Data 44% of the 44,000 new infections (=19,500) 26% occurred in women 73% occurred in Men 57% occurred in MSM 39% aged 13 to 24 48% of all persons diagnosed with AIDS From HIV Among African Americans, CDC Fast Facts, http://www.cdc.gov/hiv/group/racialethnic/africanamericans/, retrieved May 6, 2016.
HIV in African Americans 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 12% of population 44%New HIV DX 48%AIDS DX All Others African American
Florida is #1 in New HIV Cases Jan 2016 Cases increased by 23% 1 in 49 Blacks in FLA has HIV, compared to 1 in 325 whites
Adherence There has been a greater benefit of HAART on mortality in whites as compared to blacks In Non-Hispanic Blacks a higher risk of HIV mortality even among those without concurrent AIDS, indicating a need to identify and address barriers to HIV care in these populations. Examination of Inequalities in HIV/AIDS Mortality in the United States From a Fundamental Cause Perspective Marcie S. Rubin, MPH, MPA, Cynthia G. Colen, PhD, and Bruce G. Link, PhD http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2866621/ Racial-ethnic differences in all-cause and HIV mortality, Florida, 2000-2011. Trepka MJ1, Fennie KP2, Sheehan DM2, Niyonsenga T3, Lieb S4, Maddox LM5. http://www.ncbi.nlm.nih.gov/pubmed/26948103
Adherence Bogart, et.al. Medical Decision- Making 2001 * Physicians less likely to prescribe antiretrovirals to patients that are likely to be non-adherent * Same physicians felt that African-Americans less likely to be adherent to treatment
Moskowitz, MD A study of pain treatment provided for 169 HIVinfected indigent patients: PCPs trusted white more than nonwhite patients despite similar rates of reported illicit drug use or opioid misuse. Dayna Bowen Matthew, Just Medicine: A Cure for Racial Inequality in American Health Care.
Adherence Blacks had a greater rate of HAART therapy at 94% compared to 83% of whites -Oramasionwu, et al, 2009 However, Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. - M C Kong, et al, 2012 http://www.journalnma.org/article/s0027-9684(15)31110-x/pdf http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3514995/
MACH14 Study J Acquir Immune Defic Syndr. 2012;60(5):466-472. A study of 1886 participants (54% white, 28% black, 14% Hispanic) from the HIV Cost and Services Utilization Study: 40% reported having a discriminatory health care experience since their HIV diagnosis 24% failed to completely or almost completely trust their health care providers
Stereotype Threat-induced Anxiety USC and Loyola Marymont Univerity, published 2014 The affect of waiting room poster images depicting AA women in stereotypical health situations on anxiety levels of woman Black women who strongly self-identified as black reported the greatest amount of anxiety An unintended byproduct of public health campaigns is that they often communicate and reinforce negative stereotypes about certain groups of people. -Cleopatra Abdou https://news.usc.edu/65893/study-offers-new-clues-about-the-source-of-racial-health-disparities/
Health Literacy Ratzan and Parker definition as used in a 2004 Institute of Medicine (IOM) report: the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. Andrulis and Bach 2007: It s more than understanding words how a person interprets healthcare messages.
Health Literacy National Assessment of Adult Literacy 2003: 58% of Blacks exhibited basic or below basic health literacy compared to only 28% of whites. http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiod icals/ojin/tableofcontents/vol142009/no3sept09/cultural-and-linguistic- Barriers-.html
Health Literacy Low Income Lack/Type of Insurance Low Education Low Health Literacy The Health Literacy of America s Adults, Results from the 2003 National Assessment of Adult Literacy. http://nces.ed.gov/pubs2006/2006483.pdf. Retrieved May 7, 2016.
VanRyn, et.al. Soc Sci Med 2000 Race of patient affected physicians perceptions of and attitudes towards patients after controlling for covariates African Americans perceived less: pleasant, intelligent, educated, adherent to medical advice
Low Literacy Does Not Equal Low Intelligence!! Health-Related Experience is a major factor in developing Health Literacy Health Literacy Health- Related Experience
Single Item Literacy Screener (SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written health materials from your doctor or pharmacy? Answer: Never, Rarely, Sometimes, Often, Always. Threshold: If they answer Sometimes, Often or Always, support is needed. Norris NS, MacLean CD, Chew LD, & Littenberg B. The Single Item Literacy Screener: Evaluation of a brief instrument to identify limited reading ability. BMC Family Practice 2006, 7:21, available from http://www.biomedcentral.com/1471-2296/7/21.
Health Literacy Intervention Culturally and Linguistically Appropriate Services(CLAS standards) Health Coaches Community Health Promoters Clinical pharmacists
Patient Trust African Americans have been shown to have greater awareness of the documented history of racial discrimination in the health care system http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1497554/pdf/12815085.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1497554/pdf/12815085.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1497554/pdf/12815085.pdf
Jacobs, et al, 2006..the majority of respondents indicated that the race of the physician did not matter. Trust: Technical and interpersonal competence compassion, reliability, dependability, communication Distrust: Experiences and expectations of racial and financial discrimination
Racial Concordance Several studies have reported that racial discordant clinical scenarios are rated as less participatory and less satisfactory However, only 22% of AA stated a preference for an AA doctor- Arnold, Elser R, 2007 Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94:2084 2090. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient physician relationship. JAMA. 1999;282:583 589. Saha S, Komarony M, Koepsell TD, Bindman AB. Patient physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 2005;159:997 1004.
Tuskegee Syphilis Study Legacy Many participants perceived events that others would see as routine or incompetent medical care as experimentation and attributed this expectation to their knowledge of the Tuskegee Syphilis Study, whether or not they could identify the study by name. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1924632/
Religiosity African Americans are the most religious ethnic group in the U.S.- Pew Research Center, 2009. http://www.pewforum.org/2009/01/30/a-religious-portrait-of-african-americans/ A study of YMSWM identified religion and spirituality as consistent sources of strength and coping regardless of ongoing affiliation with a specific church. Foster et al. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4475678/
Religion The Black Church misnomer trivializes the religious experience of African Americans *participate in the gamut of religious denominations *churches are diverse, reflect individual communities *ignores the privately experienced interiorized religion(described by Alport, 1958).
Religion 41% of patients want to discuss religion with their doctor, but only 8% have done so. 41% recalled an instance when religion played a part in medical decision- making. Williams, J., Meltzer, D., Arora, V., Chung, G., & Curlin, F. (2011). Attention to inpatients religious and spiritual concerns: Predictors and association with patient satisfaction. Journal of General Internal Medicine. July, 1 Published Online. McCord, Gary et al. Discussing spirituality with patients: A rational and ethical approach, Annals of Family Medicine,. http://www.hpoe.org/hpoe_live_webinars/religious_competency_4_25_13_presentation.pdf
Religion Whitely(2012), proposes we adopt the notions of Cultural Safety or Cultural Humility in addressing religion (Polaschek, 1998; Tervalon & Murray-Garcı a, 1998) Puchalski, 2006 FICA assessment tool: Faith and Beliefs Importance Community Address in care http://tps.sagepub.com/content/49/2/245.full.pdf+html
Religion Religious beliefs may at different times exert different effects, both positive and negative - Elser, Arnold et al. Religion effect HTN + DM - Viewpoint: Cultural Competence and the African American Experience with Health Care: The Case for Specific Content in Cross-Cultural Education Eiser, Arnold R. MD, FACP; Ellis, Glenn
Religion a set of beliefs concerning the cause, nature, and purpose of the universe, often containing a moral code governing the conduct of human affairs. - Dictionary.com
Spirituality Spirituality uniquely predicts health and wellbeing outcomes in those with HIV/AIDS such as improvements in life satisfaction, functional health status, and health-related quality of life after controlling for factors such as age and HIV symptoms (Pargament et al., 2004). Spirituality in HIV+ Patient Care Joni L. Utley, MA & Amy Wachholtz, PhD, MDiv
Spirituality Spiritual struggle, anger, or sense of punishment has been associated with poor adherence. (Parsons, Cruise, Davenport, & Jones, 2006) Unpublished data from the Patient Centered Medical Home study at UM indicates the majority of patients seen in the HIV clinic feel less than human.
Acknowledging Religion may validate some patients who has become marginalized by Stigma or Stigma Threat Wellbeing Religion & Spirituality Patient
Religion In the UK, a clinic with a large Somali muslim community experienced a 50% no show rate, conscientious scheduling decr. the rate by 13.5 % Gatrad, A. (1999) A completed audit to reduce hospital outpatients non-attendance rates. Archives of Disease in Childhood. 82, 59-61. Retrieved from http://www.hpoe.org/hpoe_live_webinars/religious_competency_4_25_13_presentation.pdf
Summary 1. The examination of Provider bias is an integral part of improving cultural humility/competence. 2. Reviewed the historical context of AA vulnerability and current HIV disparities. 3. Low health literacy is multifactorial and does not equate low intelligence. 4. The acknowledgement of a patient s religion may be a welcomed opportunity to validate patients and strengthen the provider/patient bond.
Questions? apowell@miami.edu
This Presentation and resources are made possible by AETC grant award U1OHA29295 from the HIV/AIDS Bureau of the Health Resources Services Administration (HRSA), U. S. Department of Health and Human Services (HHS). The information presented is the consensus of HIV/AIDS specialists within the SEAETC and does not necessarily represent the official views of HRSA/HAB The AIDS Education and Training Center (AETC) Program is the training arm of the Ryan White HIV/AIDS Program. The AETC Program is a national network of leading HIV experts who provide locally based, tailored education, clinical consultation and technical assistance to healthcare professionals and healthcare organizations to integrate high quality, comprehensive care for those living with or affected by HIV.
The South FL SE AIDS Education and Training Center within the University of Miami, Department of Medicine, Division of Clinical Immunology, has over thirty faculty members and staff dedicated to caring for patients with HIV/AIDS and includes some of the world s most renowned researchers in infectious diseases. We have specialty clinics in adult medicine, and obstetrics/gynecology that provide state of the art clinical care for those individuals infected with HIV and other STIs. HIV clinical care is provided by the UM physicians for inpatient care at Jackson Memorial Hospital (JMH) and University of Miami Hospital, and outpatient care at numerous sites on the UM/JMH medical campus. UM HIV faculty also provide off site care at Federally Qualified Health Centers.
The South FL SE AETC includes the following counties: Polk, Hardee, Highlands, Indian River, Okeechobee, St. Lucie, Hernando, Pasco, Pinellas, Hillsborough, Manatee, Sarasota, DeSoto, Martin, Palm Beach, Broward, Miami-Dade, Monroe, Charlotte, Glades, Lee, Hendry and Collier.
The U.S. Department of Health and Human Services (DHHS) has released updated versions of its antiretroviral treatment guidelines for adults and adolescents, and for children with HIV. The new adult guidelines include revised recommendations for firstline antiretroviral therapy (ART) as well as management of treatment-experienced patients. The revised pediatric guidelines include a discussion of very early treatment for HIV-infected infants. References HHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Updated April 8, 2015. DHHS Panel on Antiretroviral Therapy and Medical Management of HIV- Infected Children. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. Updated March 5, 2015.
TRAINING OPPORTUNITIES Preceptorships An intensive clinical training program offered to healthcare providers in Florida who have an interest in learning more about the diagnosis and management of HIV/AIDS, opportunistic infections, and co-morbid conditions. Each preceptorship is structured to meet the unique needs of the individual participant based on his or her previous experience, geographic location, and time available. Experience 4 to 240 hours of clinical training at adult, pediatric, obstetric, and/or family practice clinics where care is provided to HIV-infected patients. All training provided is consistent with current guidelines from the Department of Health and Human Services or other nationally recognized guidelines when available. Individual and/or Group Clinical Consultations Individual and group clinical consultations are offered. Individual clinical case consultation is provided on the diagnosis, prevention, and treatment of HIV/AIDS and related conditions. These consultations take place by telephone, email or face-to-face meetings. Group clinical consultation with case-based discussions include information on pharmacology, clinical antiretroviral therapy updates, drug-drug interactions, and antiretroviral resistance.
TRAINING OPPORTUNITIES Cont d Chart Reviews The chart review program offers clinics that provide HIV/AIDS care an opportunity to assess adherence to current Department of Health and Human Services (DHHS) and other published guidelines utilized in the care and treatment of HIV-infected individuals. Using a team of specially-trained F/C AETC faculty, a review of selected patient charts is completed to identify the strengths of the healthcare team, as well as areas of opportunity for education and training to support quality improvement efforts. Web-Based Education (Webinars) We offer numerous web-based educational opportunities to increase the knowledge and skills of HIV healthcare providers. Our web-based educational opportunities cover a wide range of HIV-related topics. Trainings are provided both as live webinars or on-demand recorded webinars. Web-based education offers participants a way to stay up-to-date on current topics. Telehealth Case Based Group Consultations This model uses a live audio-video-based platform (Adobe Connect) to provide educational experiences through the creation of a learning network comprised of clinicians serving HIV/AIDS patients, novice to expert throughout our region.
FOR MORE INFORMATION, PLEASE VISIT: http://hivaidsinstitute.med.miami.edu/partners/se-aetc
National HIV/AIDS Clinicians Consultation Center UCSF San Francisco General Hospital 800.933.3413 National HIV/AIDS Telephone Consultation Service Consultation on all aspects of HIV testing and clinical care Monday - Friday 9 am 8 pm EST Voicemail 24 hours a day, 7 days a week 888.448.4911 National Clinicians Post-Exposure Prophylaxis Hotline Recommendations on managing occupational exposures to HIV and hepatitis B & C 9 am - 2 am EST, 7 days a week 888.448.8765 National Perinatal HIV Consultation & Referral Service Advice on testing and care of HIV-infected pregnant women and their infants Referral to HIV specialists and regional resources 24 hours a day, 7 days a week HRSA AIDS ETC Program & Community Based Programs, HIV/AIDS Bureau & Centers for Disease Control and Prevention (CDC) www.nccc.ucsf.edu
Upcoming Webinars Monday, JUNE 21 st Retention in Care for Transgender Clients Sheryl Zayas, DO Monday, JUNE 27 th Transitioning HIV Infected Youth to Adult Services Ana Garcia, PhD, LCSW Wednesday, JULY 27 th Antiretroviral Resistance and Resistance Testing Elizabeth Sherman, PharmD, AAHIVP
Need Additional Information? Contact the South FL SE AIDS Education and Training Center Franklin Monjarrez, Program Manager: fbm20@med.miami.edu Tivisay Gonzalez, Program Coordinator: tgonzalez1@med.miami.edu
Target audience: Physicians, physician assistants, nurses, pharmacists, social workers, mental health workers, nutritionist/dietitians. The Suwannee River Area Health Education Center, Inc. is a Florida Board of Nursing, Dentistry, Pharmacy, Psychology, Respiratory Care, Occupational Therapy, Nursing Home Administration, Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling and Florida Council of Dietetics and Nutrition approved provider of continuing education. CE Broker Provider ID #50-1922. This program meets the requirements for up to 1.0 contact hours. The Florida AHEC Network designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits.
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